Zambia

While recognized internationally for its ambitious goal of malaria elimination and for having attained pre- elimination levels in Southern Province, Zambia, as a whole remains a highly endemic malaria country, with the entire population considered to be at risk of contracting malaria.[1] It is among the 20 countries with the highest malaria incidence and mortality globally, and the country carries 1.4% of the global malaria case and death burden and 6 % of the case burden in East and Southern Africa. [2]

Risk is highest in the wetter, rural, impoverished provinces of Luapula, Northern, Muchinga and North Western (11–30% prevalence in 2018), and lowest in Lusaka Province (0.1% and Southern Province (<0.1%). [1]

Zambia’s 2018 Malaria Indicator Survey highlighted several encouraging trends:[1]

• The national infection rate in children under five years of age had decreased from 22% in 2006 to 9 % in 2018.
• 80% of households in 2018 owned at least one insecticide-treated mosquito net (ITN), an increase from 38% in 2006.
• 77% of children in rural areas, where risk is greatest, slept under bed nets in 2018, an increase from 42 % in 2008.
• 81% of pregnant women in 2018 received medications to prevent malaria, an increase from 59 % in 2006.

Between 2020 and 2021, however, malaria cases increased by just 0.4%, from 187 to 188 per 1000 of the population at risk, while mortality rates increased by 3.2% from 0.47 to 0.43 per 1000 of the population at risk. [2]

Worrisome trends also characterized 2020, including a 30–40% worsening of burden indicators in 2020 from 2018–2019 levels, including incidence, deaths, and positivity rates. Similar trends were noted across southern Africa. The trend began in Q1, prior to most in-country COVID-19 effects, and may have been due to a more conducive rainfall pattern in the 2019–2020 rainy season in setting of inadequate vector control coverage; spotty saturation of community case management of malaria; under-investment in artemisinin-based combination therapies (ACT)s and rapid diagnostic tests (RDT)s, and other factors. COVID-19 impact was felt mainly in disruption of supply chains from March 2020 onward, compounding global RDT shortages.

Zambia launched its National Malaria Elimination Strategic Plan (NMSP) in April 2018 to serve as a strategy towards a malaria-free Zambia. [3] Key tenets of the plan are equitable access to quality-assured, cost-effective malaria prevention and control interventions. [1] In March 2019, Zambia launched its first End Malaria Council (EMC), designed to increase resource mobilization to achieve and sustain malaria elimination.[1] The EMC convenes senior-level, multi-sectoral stakeholders (government, business, and community leaders) to complement Zambia’s National Malaria Elimination Programme. The EMC is is focused on:

• Ensuring the national strategic plan is implemented by driving action and holding stakeholders accountable,
• Pursuing traditional and innovative financing to mobilize domestic resources to close the existing funding gap, and
• Advocating for malaria elimination to remain high on public and private sector agendas.

In June 2019 the EMC established the End Malaria Fund (EMF). [1]The EMF is a public-private partnership to spearhead efforts toward mobilizing the country’s estimated $100 million funding gap necessary to fill in order to end malaria by 2021. The EMF’s Boardoperates as a subcommittee of the EMC and supports the Council in meeting its key strategic priorities.

Malaria Transmission 

Plasmodium falciparum is responsible for 98% of all infections although there are four main malaria parasite species present in Zambia (P. malariae, P. ovale and P. vivax are the other three). [4] 

Case management 

Zambia’s Guidelines for the Diagnosis and Treatment of Malaria in Zambia (Ministry of Health, 5th Edition, 2017) recommend injectable artesunate as the first line treatment for severe malaria. Intramuscular artemether or intramuscular/intravenous quinine are alternatives. In pregnancy, the first-line treatment for severe malaria is intravenous quinine in the 1st trimester, and injectable artesunate in 2nd and 3rd trimesters.[1] 

At peripheral health facilities, pre-referral management of severe disease with artesunate rectal capsules (ARC) (for children less than 6 years old) or injectable artesunate is recommended. [1] For community health workers, pre-referral management of severe disease with rectal artesunate (for children less than 6 years old) is recommended. [1] 

Pregnancy 

The percentage of women who received antenatal care (ANC) by a skilled provider has increased slightly from 94 percent in 2007 to 97 percent in 2018. [5] Both women attending 4 or more ANC visits and women receiving at least one ANC visit during their first trimester of pregnancy have also seen modest gains. Zambia continues to place significant emphasis on ANC attendance and expects to see continued gains in the area of ANC attendance. [5] 

In 2014, the National Malaria Elimination Program (NMEP) aligned the national policy on IPTp with the updated WHO policy on intermittent preventive treatment for pregnant women (IPTp), including updating the HMIS/DHIS2 (Health management information system/District Health Information System 2) to capture three doses of IPTp. [5] 

The current national policy calls for pregnant women to receive IPTp at every ANC visit at least one month apart up until the time of delivery, with the first dose starting as early as possible in the second trimester of pregnancy--between 13 and 16 weeks. [5] Between 2015 and 2018, there was a slight increase – from 79% to 81% – in  percentage of women who received two or more doses of IPTp during their last pregnancy in the last two years. Over the same period, the percentage of women who received three or more doses of IPTp increased from 61% to 67%. [1] 

Prevention 

In 2018, the percentage of children under five years who slept under an insecticide-treated net (ITN) was similar by sex, higher in rural than urban (77.4% versus 69.3%) and generally lower among children from the urban provinces (such as Copperbelt and Lusaka) than the rural provinces. [6] Among pregnant women, ITN use increased from 58% in 2015 to 71% in 2018. The increase in ITN use was noted among women from both rural and urban settings (52% to 63% for urban areas and 61% to 74% for rural areas).[6] 

Healthcare system 

Government-run health facilities, which provide the great majority of the healthcare in Zambia, offer a package of basic healthcare services that are provided for free or on a cost-sharing basis, depending on the location and level of the system. In rural districts these services are free.  

Malaria control interventions are delivered at all levels of healthcare facility: 

• Community 
• Health posts (subdistrict level) 
• Health centers (district level) 
• Level 1 hospitals (district level), Level 2 hospitals (provincial level), and Level 3 hospitals (central level) 

Church-affiliated facilities are common and are well integrated into the government system in terms of service delivery practices and reporting. These institutions are responsible for over 50% of formal health services in the rural areas of Zambia and about 30% of healthcare in the country as a whole. The private sector accounts for just 14% of all health facilities nationally. [1]